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kimmy2 
3:36pm, July 26, 2009
Fibromyalgia has different types and subsets.(1) More than one factor may be involved in causing it. Causes may be recognized, but the exact mechanism of how Fibromyalgia develops from this cause is not fully known. Most importantly, there is more than one way to get Fibromyalgia; it is an “end point” condition with multiple ways leading to it.
I have compiled a list of probable causes of fibromyalgia. This list is based on my experiences and understanding of the current literature. My opinions on these probable causes may not be shared by everyone. My list of probable causes is as follows:
1. Genetics,
2. Trauma(2),
3. Connective tissue disease,
4. Infection,
5. Catastrophic stress,
6. Chemical exposure.
Like trauma, infection is one of those causes of fibromyalgia that just screams for common sense.
I’ve seen hundreds and hundreds of people whose basic story goes like this: “I was fine, I got a virus, I developed fatigue and pain, and I’ve never been the same since.”
The logical thinking in this scenario is that fibromyalgia was not present before the viral infection. There may have been a hereditary predisposition or a vulnerability, but fibromyalgia was not present. The virus caused the condition to develop and it has been present since the virus and continues to be present. This is a straightforward infectious cause.
Not all infections are as straightforward.
Many people who have fibromyalgia get a viral infection and find it worsens the fibromyalgia. People with active viral infections are at risk for additional infections, particularly bacterial infections which can create additional problems.
Some people with fibromyalgia are more vulnerable to any type of infection because the fibromyalgia renders them more immunocompromised or more at risk for infection. The physician needs to sort out the various possibilities to determine whether an infection is the cause, a consequence, or an aggravator of the fibromyalgia.
The mechanism by which an infection leads to fibromyalgia is probably related to inflammatory or autoimmune changes caused by the infection that starts the fibromyalgia cascade. The actual clinical infection resolves and is long gone, yet fibromyalgia symptoms continue.
Sometimes, the infecting virus or bacteria may hang around and create a persistent low grade infection which activates the autoimmune responses, thereby “triggering” the fibromyalgia.
• Many times, though, the infection has long disappeared, but permanent changes occurred in the body, and these changes caused fibromyalgia to develop.
Various viral infections can cause fibromyalgia.
• The Epstein-Barr virus which causes infectious mononucleosis is one.
• Cytomegalovirus causes a syndrome similar to infectious mononucleosis.
• Different strains of the influenza virus can also result in fibromyalglia.
• The adenoviruses, especially Type II, cause common colds, bronchitis, and various upper respiratory infections, and may lead to fibromyalgia.
• Human Herpes Virus 6 has also been implicated.
• Reactive fibromyalgia has been described in patients with AIDS and hepatitis.
Sometimes viral titers can be directly measured to demonstrate that an acute infection has occurred. This concentration can be correlated with the clinical development of fibromyalgia. Many times, though, the exact offending virus is not known, but we can still categorize the fibromyalgia as one that was caused by an infection, probably a viral infection, if it fits clinically.
Bacterial infections can also cause fibromyalgia.
I have seen patients who have developed fibromyalgia after sepsis (blood infection) and salmonella infections, and one who, I felt, has gotten it from a Listeria infection. Some research studies found Mycoplasma incognitos and Chlamydia pneumoniae(3) in patients with fibromyalgia and chronic fatigue syndrome.(4) These infectious organisms may be causing some of the symptoms.
Indeed, some of the patients improve with antibiotic therapy. Gulf War Syndrome, in part, may have been related to infections from one of these bacteria. Symptoms of Gulf War Syndrome include fatigue, headaches, depression, joint and muscle pain, sleep disorders, and poor memory (sound familiar?). [Note: As of November 2008, a research panel reported their finding that Gulf War illness is real, and “is the result of neurotoxic exposures,” as discussed in Chapter 10 under Chemical Exposure as a probable cause of FM.]
Fibromyalgia can be caused by yeast and parasite infections.
I have seen some patients who developed it following a severe Candida yeast infection, and others following parasite infections such as Giardia. Most of the time, yeast or parasite infections occur in patients after the fibromyalgia has already developed. These infections may aggravate the preexisting fibromyalgia or cause it to flare up.
Fibromyalgia may predispose us to these infections by interfering with our immune function. On the other hand, these infections can sometimes cause the fibromyalgia by “triggering” the fibromyalgia cascade. Many of the symptoms of a chronic Candida yeast infection(5) - such as fatigue, irritable bowel syndrome, bloating, allergies, altered immune response, and skin conditions - overlap with fibromyalgia symptoms. This can make it difficult to “separate” the two conditions and determine cause and effect relationships.
As I’ve mentioned, some infections come in, do their damage and disappear. The infectious agent is no longer present in the body and thus can’t be detected at a later point in time. Other infectious agents may hang around in the body and establish a chronic infection; one that perhaps can be detected with blood tests.
What remains to be seen is whether these chronic infections can be eradicated with antibiotic treatment and, if so, will the fibromyalgia symptoms disappear? Or has the fibromyalgia already established itself as a separate entity which does not disappear with the antibiotic treatment?
Hopefully we will have these answers in the near future. [But]… one thing is certain: We will continue to learn more about fibromyalgia and understand it better.
___
1. See also Dr. Pellegrino’s articles on: “The Fibromyalgia Spectrum – Part of the Big Picture in Understanding Fibromyalgia” and “Fibromyalgia – Ultimately a Disease of Amplified Pain.”
2. See also Dr. Pellegrino’s article on: “Fibromyalgia as a Complication of Injuries”
3. For more on this subject, see “Chlamydia Pneumoniae in Chronic Fatigue Syndrome and Fibromyalgia – An Opinion,” by Patient Advocate James Kepner, from the Chlamydia pneumoniae Help website.
4. See “Evidence for bacterial (mycoplasma, Chlamydia) and viral (HHV-6) co-infections in chronic fatigue. See “Evidence for bacterial (mycoplasma, Chlamydia) and viral (HHV-6) co-infections in chronic fatigue syndrome patients,” by Dr. Garth Nicolson and Dr. Darryl See.
5. See also Dr. Pellegrino's article on: "Candidiasis - Yeast Infection and Nutritional Repair."
* This article is excerpted with kind permission from Dr. Pellegrino’s very popular book Fibromyalgia: Up Close & Personal, © Anadem Publishing, Inc. and Mark Pellegrino, MD, 2005, all rights reserved. This book may be ordered in the ProHealth.com store (see new products).
Note: This information has not been reviewed by the FDA. It is generic and is not intended to prevent, diagnose, treat or cure any illness, condition, or disease. It is very important that you make no change in your healthcare plan or health support regimen without researching and discussing it in collaboration with your professional healthcare team.
3 HOW CAN I AVOID CATCHING SWINE FLU?
In very simple terms, the more people you come in contact with the higher the risk - especially from people who are coughing or sneezing. The highly contagious time for people who have the virus is around the time when they have first have symptoms. So try to keep away from crowded public areas and public transport, including aeroplanes – if it's not really necessary. This is particularly important if you have an 'at risk' condition (see point 7) as well. Simple avoidance measures and hand washing will help to reduce the risk but you cannot eliminate risk completely. Coughing and sneezing also spreads viral droplets onto hard surfaces such as door handles, keyboards and phones – where they can remain infective for up to 24 hours. This is another important form of transmission. Wearing a cheap face mask isn't thought to be a very effective form of protection!
People in high risk groups (see point 7), especially those with respiratory/lung disease, must make sure that their symptoms are under good control (asthma in particular) and that any chest infection is promptly treated. And stop smoking if you do!
If you are working your employer should be taking sensible precautions to cut down the risk of transmission – ie advising sick employees to stay at home and providing antiseptic wipes to clean hard surfaces such as keypads which have multiple users.
4 HOW CAN I BUILD UP MY RESISTANCE TO CATCHING SWINE FLU?
The media is full of advice from 'health experts' about how to 'boost your immune system' using vitamin C, Echinacea and all kinds of expensive unproven supplements. However, there is no sound scientific evidence to show that these products make any real difference.
5 HOW DANGEROUS IS SWINE FLU?
At present, the virus appears to be of similar virulence to any other type of flu virus – but it appears to be causing more severe respiratory symptoms in some people. So the vast majority of people are experiencing a relatively mild illness. If the virus starts to mutate (ie swap or change its genetic make up) and different strains emerge then the situation could become more serious quite quickly. As with any other flu like virus, there are going to be occasional cases where perfectly healthy people develop severe complications (such as pneumonia). People with 'at risk illnesses' – such as asthma or cancer – are more likely to develop potentially serious complications. This is the reality of any infectious disease.
6 ARE PEOPLE WITH ME/CFS MORE AT RISK OF DEVELOPING COMPLICATIONS FROM SWINE FLU?
Overall, there is no evidence to indicate that people with ME/CFS are more at risk from developing the serious complications that can occasionally occur with swine flu. However, those who are more severely affected, especially anyone who is bed-bound or prone to chest infections, may be more at risk from respiratory complications. And as many people with ME/CFS experience a relapse or exacerbation in symptoms whenever they catch a viral infection, an episode of swine flu is highly likely to make ME/CFS worse. Feedback so far (section 17) confirms both of these assumptions.
7 DOES IT MAKE ANY DIFFERENCE IF YOU HAVE ANY OTHER MEDICAL CONDITIONS?
Yes, it can make a very significant difference. Because swine flu is an infection that predominantly affects the respiratory tract/lungs, those with any form of respiratory disease – asthma, chronic bronchitis and COPD/chronic obstructive pulmonary disease in particular – are more at risk from developing potentially serious respiratory complications. So if you already have a chronic lung disease, it's important to make sure that you are controlling symptoms with medication as well as possible.
Other illnesses and situations that increase the likelihood of serious complications include:
diabeteschronic liver and kidney diseasechronic neurological disease, especially those that affect respiratory function. NB The Department of Health accepts the WHO classification of ME and CFS as being neurological. chronic heart diseaseimmune system deficiency/suppression caused by cancer, leukaemia and drugs such as steroids pregnancy – especially during the third trimester - where the immune system is naturally suppressedyoung children under 5the over 65s – although people over the age of of 60 may have some partial immunity to the virusRegarding pregnancy: A report from American researchers published in The Lancet found that pregnant women are four times more likely than the general population to need hospital treatment for H1N1. Pregnant women should therefore make contact with their GP as soon as possible if they develop flu-like symptoms. The inhaled antiviral drug Relenza (see point 12) is considered safe to use in pregnancy because it reaches the throat and lungs, where it is needed, and does not reach significant levels in the blood or placenta. Pregnant women should also have swine flu vaccination – unless there are good reasons for not doing so.
Although a variety of immune system abnormalities can occur in ME/CFS, these are not usually consistent with the sort of immune system deficiency that makes people much more susceptible to this type of infection.
8 WHAT ARE THE MAIN SYMPTOMS OF SWINE FLU?
At present, swine flu tends to present with an acute onset with some or all of these typical flu like symptoms:
Where mild, the illness tends to last for about a week.
You can do a very helpful 9 HOW CAN YOU TELL THE DIFFERENCE BETWEEN ME/CFS FLU-LIKE SYMPTOMS AND SWINE FLU?
This may not always be easy as some of the symptoms clearly overlap. But swine flu should always be considered where there is a new or sudden onset of flu-like symptoms – especially if this includes sneezing and cold-like symptoms, respiratory symptoms or a cough, and a definite fever. Most people with ME/CFS who have had swine flu also report a fever. The key advice here is to trust your instinct – if something different with flu-like symptoms is clearly happening seek medical advice.
It's worth noting that a variety of plant and tree pollens can cause sneezing, coughing and other hay fever-type symptoms at this time of year – which may add to the confusion over diagnosis.
10 CAN SWINE FLU TRIGGER ME/CFS IN PREVIOUSLY HEALTHY PEOPLE?
As infections are a very common trigger for ME/CFS, and we know that ordinary flu can trigger ME/CFS, the answer is almost certainly yes. The MEA contributed to a very helpful article in The Guardian on this issue::
11 WHAT SHOULD I DO IF I HAVE NEW FLU-LIKE SYMPTOMS THAT DO NOT SEEM LIKE ME/CFS?
For the vast majority of people an episode of swine flu will not be that all that different from any other type of flu. This can be normally treated at home with rest, plenty of fluids and painkillers (paracetamol or ibuprofen). Swine flu symptoms tend to last for no more than a week.
12 WHAT ARE TAMIFLU AND RELENZA?
Tamiflu (oseltamivir) is an effective antiviral drug that works by reducing the replication of the virus. Tamiflu will:
If you have an illness such as asthma that puts you at increased risk of developing complications from swine flu it's important to start taking Tamiflu as soon as possible. To be effective the drug really needs to be used within 48 hours of the onset of symptoms. Antiviral drugs are being given out by doctors in relation to individual clinical circumstances - they are not necessary in every case. And they are not normally being given as a prophylactic/preventative measure to contacts of cases –unless there are special circumstances.
Tamiflu side-effects can include nausea, which appears to be the most common. Nausea can be reduced by taking the drug with or immediately after food and drinking some water. Other possible side-effects include vomiting, abdominal pain, dyspepsia, diarrhoea, headache, fatigue, insomnia, dizziness, conjunctivitis, epistaxis (nose bleed) and a rash. Very rare but more serious side-effects include hepatitis, Stevens-Johnson syndrome, toxic epidermal necrolysis and neurospychiatric disorders. The drug should not be taken by people with kidney disease and not normally during pregnancy (where safety to the foetus remains uncertain). Tamiflu can be given to children. A liquid preparation is available for children and people who cannot take tablets.
Relenza (zanamivir) is another antiviral drug. This drug is inhaled and is suitable for use in pregnancy. However, it can cause bronchospasm (airways spasm), urticaria ('hives')and skin rashes. It needs to be used with caution in anyone with asthma and lung disease.
13 SHOULD PEOPLE WITH ME/CFS TAKE TAMIFLU?
The simple answer at present is probably yes – but this is clearly a decision that has to be made in relation to individual circumstances. Tamiflu appears to be a generally safe and effective treatment with a low level of side-effects. So Tamiflu is a drug that should be seriously considered when a person with ME/CFS develops swine flu, or has symptoms suggestive of swine flu – the main reason for use being that the swine flu infection could well cause a significant exacerbation of ME/CFS.
As noted in point 12, one of the rare side-effects is neuropsychiatric disorders – so this drug does need to be used with extra caution in anyone, especially children, who have a past or current history of significant mental health problems.
15 SHOULD PEOPLE WITH ME/CFS BE VACCINATED AGAINST SWINE FLU?
Now that the genetic make-up of the swine flu virus has been identified, scientists have been able to rapidly develop a vaccine that is based on a killed virus. In simple terms it is comparable to the normal seasonal flu virus vaccine but only gives protection against the swine flu virus. It does not offer any protection against common seasonal flu viruses.
There are two brands of swine flu vaccine now being used – Pandemrix and Celvapan.
Pandemrix only requires one dose. This vaccine is prepared in hen's eggs so should not be given to people who are allergic to egg products.
Celvapan requires two doses. This vaccine is not prepared using eggs – so it can be used in people with egg allergy.
The vaccine is first being offered to people who are more likely to become seriously ill if they develop swine flu – see the bullet point list in section 7. In addition, it is being offered to health service staff and people who live in the same house as someone whose immune system is compromised by disease or treatment. For the purpose of ME/CFS it can be argued, if necessary, that people with ME/CFS are in a high priority category as they have a chronic neurological disorder as classified by the World Health Organisation and accepted by the Department of Health. However, GPs may not accept this reasoning on the grounds that people with ME/CFS are not at special risk from swine flu.
People who are not in one of the high priority groups will be offered the vaccine at a later stage - possibly during November.
All vaccines can produce side-effects. Minor ones such as redness, soreness, fever and headache are quite common. More serious ones do occur but they are rare. Concern has been expressed about whether the clinical testing of swine flu vaccine prior to widespread use has been adequate. The Department of Health is confident that the vaccine pre-use safety checks are adequate and that the vaccine is safe – but some health professionals are not yet convinced and will not be using it themselves. Concern has also been raised about the risk of Guillain Barre syndrome – a rare and serious neurological reaction that was occasionally reported in the 1970's in America following a decision to rush out a swine flu vaccine (which is not the same as the one now being offered).
When it comes to swine flu vaccination and ME/CFS there isn't a simple yes/no answer. We know from a large number of anecdotal reports that vaccines, including ordinary flu vaccine, can sometimes trigger ME/CFS or cause an exacerbation or relapse of ME/CFS symptoms. At the same time swine flu is likely to cause a significant relapse of ME/CFS symptoms.
Anyone with ME/CFS who also has one of the high risk medical conditions listed in section 7 should certainly discuss having the vaccination with their GP. So should health workers who are likely to come in contact with swine flu patients. For those who do not fall into these categories this is very much an individual decision - but as with any other vaccine it would be sensible to defer vaccination if you have an infection or a lot of flu-like ME/CFS symptoms. Having an adverse reaction to flu vaccine in the past would also need to be taken into consideration.
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